2.0 Analysis 2.1 Awareness of Vessel's Position The bridge operator did not respond to either the VHF radio call from the Windoc or to the ship's whistle blasts, which were intended to alert him to the fact that the ship was not clear of the bridge. It is unlikely that the operator could have heard the VHF radio transmission, given the noise level in the bridge control room when the bridge is in operation. TSB examination of the bridge control room of Bridge21, which is very similar to that at Bridge11, indicated that the maximum noise level experienced while the bridge is being lowered in normal operation is 92.5decibels A scale (dBA).16 Other operators indicated that they sometimes hear VHF transmissions while the bridge is in operation, but that it is not possible to understand the content of those transmissions. In this case, given the proximity of the whistle to the bridge, and the high pitch and decibel level of the whistle, the operator should have been able to hear the ship's whistle. Residents upstream of the bridge reported coming out of their homes to investigate the reason for the repeated whistle blasts. Nonetheless, the bridge operator described having seen the stern of the vessel through the north windows of the control room where the door is located. If this were the case, the vessel would have been clear of the bridge at the time the bridge span was lowered. Analysis of the ship's position before and at the time of impact shows that the superstructure of the Windoc was clearly visible through the south windows of the control room when the operator began lowering the bridge (see section 1.15, figures1 and 2). 2.2 Effects of Medication and Alcohol on Operator Performance In the absence of medical testing, which was not conducted following the occurrence, it was not possible to determine exactly which substances may have affected the operator's behaviour. Assuming a normal rate of metabolism for Darvon-N, the bridge operator would have had propoxyphene and norpoxyphene in his system at the time of the accident. Without toxicological test data, specific concentrations of these substances could not be determined. Even if toxicological data were available, it may not have been possible to determine specific effects of the known substances on performance due to numerous variables which influence the speed at which an individual metabolizes these substances and the impact of the substances on an individual's performance. Quantitative analyses conducted by the NTSB speech analysis group were significantly affected by the lack of a definitive sample of the operator's unimpaired speech. Although sample communications from the months preceding the occurrence were submitted for examination, the speech analysis group could not ascertain that the speech contained in these samples was free of the effects of fatigue and other potential influences. Speech analysis group members observed multiple occasions throughout the baseline sample where the operator sounded less than fully alert. Therefore, changes in physical properties of the bridge operator's speech which would indicate short-term impairment by alcohol, drugs or fatigue were not observed. There were no statistically significant differences in fundamental frequency, speaking rate, latency or speech errors when speech samples from the night of the accident were compared to baseline samples taken from the months preceding the accident. A further review by the speech analysis group focussed on the content and quality of the operator's speech on the night of the occurrence. This review revealed patterns which have been associated with performance impairment from alcohol and prescription medications. The group noted that the intelligibility of the operator's speech deteriorated between the time the operator came on duty at 1830 on the day of the occurrence and the period immediately preceding the accident. Spectrographic analysis indicated careless articulation or slurring in the communications which immediately preceded the accident to a greater degree than previous communications that evening. With reference to the operator's speech at the time of the occurrence, the speech analysis group noted: . . . the bridge operator's speech sounded forced and sometimes difficult to understand before the accident. Compared to earlier speech, in which the operator engaged in cordial joking with his co-workers, the operator seemed slow in thinking and his expressive tone did not always match that of the previous speakers. He twice misidentified his co-worker (with whom he had joked earlier), and seemed confused regarding the telephone difficulties and the accident itself.17 These observations of the operator's behaviour during the period of the occurrence suggest that the operator's performance was likely impaired when deciding to lower the vertical-lift span. The DSMIV18 definition for substance intoxication includes clinically significant maladaptive behavioural or psychological changes that are due to the effect of the substance on the central nervous system (e.g.belligerence, mood lability, cognitive impairment, impaired judgement, impaired social or occupational functioning). The DSMIV criteria for alcohol intoxication are similar with the addition of any one or more of the following signs: slurred speech, uncoordination, unsteady gait, nystagmus, impairment in attention or memory, stupor, or coma. As revealed by the recorded communication, in the period surrounding the accident, the operator's confusion, slurred speech, impaired memory, and lack of appreciation for the seriousness of the event are consistent with substance and/or alcohol intoxication. Comments made by TCC controllers following their conversation with the bridge operator indicate that they may have entertained this possibility. Therefore, it is likely that the operator's performance was impaired while the bridge span was lowered onto the Windoc. 2.3 Fitness for Duty for Safety-sensitive Positions It is imperative that persons, assigned to positions where their actions can have a major impact on the safety of persons, property, or the environment, are fit for the tasks to be performed. Safety-sensitive positions were not identified or defined, since SLSMC considered all operations and maintenance positions to be safety-sensitive, given the nature of their work. However, the system did not ensure that individuals occupying such positions were competent and fit for duty. At the time of the occurrence, new employees hired by SLSMC were given a pre-employment medical examination, which included a standard medical history and a physiotherapy assessment. Following this medical examination, permanent employees were not reassessed periodically unless there was specific reason to do so, such as an employee returning to work following a workplace injury when employees were required to have a medical certificate from the doctor. The decision regarding fitness for duty was taken by a physician contracted to SLSMC following a clinical evaluation of available information. If SLSMC was not satisfied with information provided by the employee's attending physician that the employee was fit for duty, then the employee could be sent to a company-appointed physician for a medical. Disclosure of current medication in these instances was at the discretion of the employee. Although there was no impediment for the employer to ask about medication, neither was there any requirement for the employee to disclose medication. The possible impact of medication on an employee's performance was considered when the decision was taken to allow the employee to return to work. To ensure privacy, and in keeping with the human rights legislation on the disclosure of personal information, this information was maintained by the occupational health nurse. Coordinators and managers were informed when an employee is able to return to work and of any restrictions on his or her abilities, but they would not be made aware of specific medical conditions or medication an employee may be taking. These procedures were identical for all positions throughout SLSMC. The operator involved in this occurrence had a history of chronic back pain stemming from a work-related injury in 1985. This condition resulted in repeated absences from work and was treated with rest and analgesics, including Darvon-N and other narcotics. SLSMC's medical documentation concerning the bridge operator contained no record of the operator taking Darvon-N. Darvon-N affects the central nervous system and as such, patients are cautioned that the medication may impair mental or physical abilities required for the performance of potentially hazardous tasks such as operating a motor vehicle or machinery. It would be unusual for an occupational physician to approve an individual who is taking Darvon-N regularly for occupying a safety-sensitive position. However, in order to make an accurate assessment, the physician would need to be made aware of both the medication being taken and the safety-sensitive nature of the work to be performed. Without a requirement to disclose medication and a system for identifying safety-sensitive job functions, the physician would be unlikely to make an informed assessment. The regime in place for monitoring the medical fitness of employees, particularly those in safety-sensitive positions, was therefore less than adequate. 2.4 Employee Supervision The bridge operator represents the sole line of defence for ensuring that the area below the bridge is clear of vessel traffic before the bridge is lowered. Training and supervision of bridge operators is therefore important for ensuring safety in the bridged areas of the St.Lawrence Seaway. Employees normally become bridge operators after acquiring sufficient seniority to receive training, which was largely conducted on the job with an experienced bridge operator. Prior to becoming fully qualified as a bridge operator, an employee must complete a written test on normal and emergency modes of bridge operation and be observed operating the bridge in its various modes by a coordinator. Once qualified to operate the bridge, there is no requirement for recurrent training or requalification. An employee normally works as a relief bridge operator until enough seniority is gained to occupy the bridge operator position on a full-time basis. Significant time may pass between the point employees qualify to operate the bridge and the time they occupy the position. Once occupying the position, bridge operators work 12-hour shifts alone on the bridge. Their only interaction is by telephone or VHF radiotelephone with the TCC and in person with coordinators during visits to the bridge. There was no requirement for coordinators to see the bridge in operation during their visits, and they would not normally visit at night unless there was a specific problem. Given these practices, there was little opportunity for coordinators and managers to observe specific employees for competence and fitness for duty. If an employee were experiencing difficulties at work, it would have been difficult for a coordinator/manager to detect them. There are few formal procedures for monitoring performance and safety between peers. Shift handovers on the bridges are informal. The lack of a specific procedure for shift handover means there is little opportunity for bridge operators to observe the fitness of individuals replacing them. TCC controllers have frequent verbal interaction with bridge operators; however, on the night of the occurrence, the controllers on duty did not inform anyone of their concerns with respect to the bridge operator or take any action to ensure he was fit to continue working. In summary, bridge operators spend a significant amount of time working alone, and there was little opportunity for management to ensure operators can consistently perform their job functions in an appropriate and safe manner. 2.5 Shipboard and Municipal Firefighting Capabilities Because of the speed at which a shipboard fire can spread, it is critical that a fire be contained as soon as it is discovered. Once the initial air/fuel vapour explosion occurred in the upper engine room casing and boat deck of the Windoc, the immediate supply of fuel for the fire was limited. Videotape recordings of the occurrence show that the firefighting response by the ship's crew was effective in containing and reducing the fire burning on the boat deck. The master, fearing an engine room fuel oil day tank explosion and observing municipal firefighters arriving on the adjacent canal bank, withdrew the shipboard fire teams to a safe position forward of the accommodation superstructure. The shore-based firefighters, however, were not equipped with boats to safely access the Windoc where it lay just offshore. Although shipboard hoses were left directed to contain the fire, attempts to extinguish it were delayed for several hours while shore-based fire crews obtained suitable boats and boarded the vessel, resulting in the fire spreading to the flammable internal structure of the accommodation. To ensure watertight integrity in adverse weather, openings in vessels can be closed and secured. These same features, such as watertight doors and ventilation dampers, also ensure that the vessel can be rendered airtight in the event of a fire. As a result of initial firefighting and prompt actions by the Windoc's crew to close dampers and watertight/fire doors, the fire was limited to the engine room casing and aftermost area of the accommodation when municipal firefighting teams boarded at 0130 on 12August 1999. The municipal fire department's arrival on scene was timely; however, once on scene, crews were confronted with a situation for which conventional shore-based firefighting training had not prepared them. Due to the watertight integrity of the accommodation structure, water applied to the vessel from the shore-side aerial ladder truck had little effect on the fire, beyond its use as peripheral boundary cooling. Once on board, the shore-based firefighting team was reluctant to enter the burning accommodation. They did not appreciate that the fire was partly contained by the airtight integrity accorded by sealed dampers and watertight doors. Based on the shore-based firefighters' training and experience, opening watertight doors to ventilate smoke from the vessel may have seemed an appropriate tactic; in fact such actions allowed fresh air to reach the smouldering fire and caused the fire to rapidly spread forward through the accommodation superstructure. The responding fire department's lack of training and experience for fighting shipboard fires and the unavailability of equipment to access the vessel hindered firefighting response. The vessel had more than one set of fire-fighting plans on board. As all copies of the plans were located within the aft superstructure, they became inaccessible at the time of the fire. A fire control plan generally includes information on the location of various fire sections, sprinkler systems, fire extinguishing appliances (e.g. fire hydrants, fire hoses, international shore coupling, etc), ventilation system, and the means of access to different compartments. Information contained in such a plan is essential to make informed decisions to effectively and efficiently fight fires; time is of the essence. Good seamanship practices dictate that a set of fire control plans be stored in a weather-tight container outside the deckhouse to assist shore-side firefighting personnel. The benefit of such a practice has been recognized by the International Maritime Organization (IMO) and is reflected in Chapter II-2, Regulation 20 of the International Convention for the Safety of Life at Sea (SOLAS) and Maritime Safety Committee Circular 451 (MSC/Circ.451) Guidance Concerning the Location of Fire Control Plans for Assistance of Shoreside Fire-fighting Personnel and also by TC in the regulations that apply to convention vessels. In spite of the safety benefits associated with such a requirement, Canadian non-convention vessels such as the Windoc are not given the same consideration. Provision of a fixed accommodation sprinkler system on board older vessels is intended to provide an equivalent level of safety for those vessels whose internal accommodation structures and partitions are comprised of combustible material. The effectiveness of such systems however can be compromised if the pipework is attached structurally to combustible surfaces. Post fire examination of the Windoc disclosed that the sprinkler system piping had been attached to combustible components of the accommodation which, once burnt, allowed the pipework to collapse, rendering the system ineffective when it was activated. 2.6 Emergency Preparedness Planning, training and exercising at the local level is the most effective means for preparing to respond to emergency situations. Strategies that facilitate an appropriate and measured response to an emergency situation should be documented in a contingency plan for the benefit of those involved in emergency response. Response action decisions need to be made and documented before an emergency occurs. Preparedness can be further enhanced by provision of training and periodic exercises, which help identify shortfalls in the plan. Training ensures that personnel are prepared to respond. Exercises test decisions and improve overall preparedness. In general, there are five phases of emergency response: alert and notify personnel, resources and authorities; evaluate the incident and mobilize personnel and resources; conduct response operations; terminate the response; and debrief personnel to evaluate the response. These phases should be detailed in a contingency plan. In actual practice, these phases often overlap while responding to an emergency. Difficulties and shortcomings were noted in connection with the emergency preparedness of SLSMC, Thorold and St. Catharines fire departments and ambulance services. 2.6.1 St. Lawrence Seaway Management Corporation SLSMC contingency plans in place for responding to vessel-related emergencies within the canal were inadequate and outdated.19 They were neither used at the time of the accident nor made available to personnel, some of whom were not aware of their existence. Early communication of key information is paramount to emergency services, particularly when responding to threats to life and property and in connection with a need to evacuate an area. Approximately three minutes after Bridge11 struck the Windoc, TCC controllers began to field calls from police, fire department and ambulance services for information about the accident. The TCC controllers, who had already spoken with the Bridge11 operator and were aware that the bridge was lowered onto the vessel, only disclosed some of the information they had at the time. Information concerning the well-being of the bridge operator was not communicated to emergency services. Furthermore, information about the vessel and its cargo was not made available until it was requested by the fire department. SLSMC cameras did not provide controllers with a clear view of the vessel and the bridge, and controllers did not request information from emergency services or SLSMC personnel who were on scene. Consequently, those responders who were in contact with the TCC controllers and en route to the accident site were not provided details about the accident and were unable to prepare themselves in advance of their arrival. Information about the condition and location of the vessel would have assisted the coordination of the emergency services and SLSMC personnel. Communication protocols and call-out or notification lists were not in place to assist TCC controllers in alerting emergency response organizations and services. A standby list for 10-17August 2001 was in place and available to TCC controllers. The list included SLSMC personnel only and primarily identified personnel available to respond to day-to-day operational matters. The Traffic Control Manual, Niagara Region, 2000, included information on reporting an accident or incident. TCC controllers forward information about an accident or incident to the marine services coordinator who, in turn, is to provide this information to CCG. The authoritiesTC, CCG, Ontario MoE's SAC, Environment Canada (EC) and TSBwere not immediately notified of the accident. Excluding TSB, authorities became aware of the accident as a result of media enquiries approximately one hour after the striking. When authorities called the TCC for additional information, controllers again provided little of the information that was available. This delay in communicating with authorities increased the risk of injuries to persons and damage to property and the environment. The availability and timely deployment of containment booms are critical to minimizing environmental damage caused by the release of pollutants onto the water. In this occurrence, it took six hours to locate and deploy an oil containment boom. The lack of pre-accident arrangements for acquiring oil response equipment further increased the risk of injury to persons and damage to property and the environment. Exercises conducted in 1996 and the boom deployment exercises were limited in scope and such that the appropriateness and measured response of multiple agencies to an emergency could not be adequately assessed. This is reflected in the absence of an appropriate, current contingency plan for responding to vessel-related emergencies and the lack of emergency-related training of SLSMC personnel, all of which contributed to difficulties experienced in responding to the accident. In essence, SLSMC's overall response to the accident was conducted in an ad hoc manner, hampering coordination and deployment of response personnel and equipment. 2.6.2 Effective Use of Available Firefighting Resources Shipboard fires are infrequent in most jurisdictions; many municipal fire departments have not had an opportunity to respond to such an emergency. When called upon to deploy to a shipboard fire, prior familiarization with vessels and the nature of shipboard fires is therefore vital. Also, emergency response centres should be aware of the capabilities and experience of the response units they dispatch. Bridge 11 lies within the jurisdiction of the Thorold Fire Departmentthe only fire department within the canal area which did not have shipboard firefighting experience or training. Common practice in shore-based fire response dictates that the first fire department to arrive on scene assumes overall command of the response. It is incumbent upon the department to closely examine the situation vis--vis its own knowledge, experience and capabilities and to request further assistance when necessary. Other than a request for boats, no assistance was requested of nearby, more experienced fire departments. As a result, available firefighting resources in the canal area were not effectively utilized to contain and extinguish the fire in time to prevent the vessel's accommodation from being destroyed. 2.6.3 Vessel Communications with Seaway and/or Bridge 11 In the case of a problem with Seaway operations, direct, clear and timely communications represent a defence to ensure safety. In a radio call, intended to alert the TCC to the bridge being lowered, the master of the Windoc did not identify himself or the bridge in question. However, he was in the wheelhouse of a vessel rapidly approaching a bridge being lowered towards him and wished to convey warnings as quickly as possible. Even if standard radio communications procedures were followed, it is unlikely that the bridge operator would have been alerted. Machinery noise levels on vertical-lift bridges in the canal are such that VHF radio communications cannot be effectively monitored by bridge operators. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The approaching Windoc was visible from the control room at the time the bridge operator started lowering the bridge. It is likely that the operator's performance was impaired at the time of the occurrence. Safety-sensitive positions were not identified or defined within SLSMC and the system in place to ensure that individuals occupying those positions were competent and fit for duty was inadequate. SLSMC's response to the accident was conducted in an ad hoc manner, which hampered coordination and deployment of response personnel and equipment. The responding fire department's lack of training and experience for fighting shipboard fires, the lack of equipment to access the vessel, and the non-accessibility of fire control plans hindered an effective firefighting response. Available firefighting resources in the WellandCanal area were not effectively utilized to contain and extinguish the fire in time to prevent the vessel's accommodation from being destroyed. 3.2 Findings as to Risk The SLSMC regime in place for monitoring the medical fitness of employees, particularly those in safety-sensitive positions, was less than adequate. The bridge operator represented the sole line of defence for ensuring the area below the bridge is clear of vessel traffic before the bridge is lowered. Bridge operators spend a significant amount of time working alone, and there was little opportunity for management to ensure they can consistently perform their job functions in an appropriate and safe manner. Machinery noise levels on vertical-lift bridges in the WellandCanal are such that bridge operators cannot effectively monitor VHF emergency communications when the lift span is in motion. The sprinkler system installed on the Windoc was rendered ineffective when the combustible structures supporting it burned, causing the pipework to collapse. 4.0 Safety Action 4.1 Action Taken 4.1.1 Advisory on Medical Fitness of Employees In November 2001, TSB sent Marine Safety Advisory (MSA) No. 08-01 to SLSMC advising them of the less-than-adequate regime in place for monitoring the medical fitness of SLSMC employees, particularly those in safety-sensitive positions. In response, SLSMC took the following steps: a draft policy on drug and alcohol procedures, including testing, has been prepared; a new Attendance Management Program, a Code of Conduct and a Code of Discipline have been implemented to provide employees with management's expectations and a process for corrective actions; and the corporate sick leave procedure with respect to submitting documentation has been modified. In addition, SLSMC is currently: identifying safety-sensitive positions; and considering retaining the services of an occupational health physician. 4.1.2 Advisory on Emergency Preparedness In January 2002, TSB sent MSA No. 02-02 to SLSMC concerning the adequacy of their emergency preparedness for responding to vessel-related emergencies within the Seaway. In response, SLSMC established an emergency planning committee. The committee will be responsible for completing the following by December 2002: development of a SLSMC emergency preparedness policy; review and update existing contingency plans; coordinate plans with external agencies; identify and develop training programs; develop training exercises; and promote emergency preparedness. Upon completion of the above work, the emergency planning committee will be responsible for updating the plans and monitoring exercises. The committee will also be responsible for reporting its progress annually to the SLSMC management committee. On 29 May 2002 an emergency preparedness policy had been developed. One SLSMC employee has since received training in exercise design. 4.1.3 Advisory on Supervision of Bridge Operators In February 2002, TSB sent MSA No. 03-02 to SLSMC concerning the adequacy of supervision of bridge operators to ensure that they can consistently perform their job functions in an appropriate and safe manner. In response, the Corporation restructured its operations, effective with the opening of the 2002navigation season. Four new shift supervisor positions have been created to supervise operational staff, including bridge operators, in the WellandCanal. Shift supervisors must also visit the operator at every bridge on every shift. Shift supervisors report to the area manager who, in turn, reports directly to the vicepresident, NiagaraRegion. An initiative is underway to control bridge operations remotely from an operations centre, where additional supervision of the operators can be provided. SLSMC will also implement procedures for the verbal handover at the end of a shift between bridge operators. 4.1.4 Advisory on Marine Firefighting In March 2002, TSB sent MSA No. 05-02 to TC, noting the continuing risks posed by the disparities in the readiness of shore-based firefighters to respond to shipboard fires. The advisory further suggested that TC, in cooperation with federal, provincial and municipal agencies, may wish to take further action to ensure that firefighters located in municipalities contiguous to port and seaway facilities in Canada are trained and equipped to effectively respond to shipboard fires. In response, TC indicated the following initiatives it had taken since 2000: TC made available 77 international shore connectors for use by local fire departments in three (Atlantic, Ontario, and Pacific) of the five regions. In the QuebecRegion, there are 12locations where connectors are available for use by firefighters. Four regions (Atlantic, Quebec, Ontario and Pacific) implemented measures to put into place emergency plans at selected ports and port facilities. There are 49emergency plans in place at public ports and public port facilities. Awareness sessions were given in four regions (Atlantic, Quebec, Ontario and Pacific) for firefighters who may be called to respond to a shipboard fire at a public port. The sessions provided information, for discussion purposes, on dealing with shipboard fires. A total of 37sessions were held at 31ports and communities and 1023persons attended. At an October 2002 meeting of the operational group of the Association of Canadian Port Authorities held in PrinceRupert, BritishColumbia, a presentation highlighted that serious shipboard fires are possible, that municipal crews are untrained, and there is a need for pre-incident coordination. 4.1.5 Municipal Fire Departments/SLSMC Firefighting Initiatives Following this accident, fire departments for four municipalities (including the Thorold Fire Department) along the Welland Canal established two regional committees to examine firefighting capabilities. One committee addresses the issue of fire fighting equipment for response to shipboard fires. The other addresses training issues, including training related to the United States National Fire Protection Association guidelines for marine firefighting, and standard operating procedures. Both committees have held meetings over the past year and have met with SLSMC and some shipping companies. The Thorold Fire Department has begun a program of visiting vessels which are laid up in the Welland Canal during the winter months, in order to familiarize themselves with shipboard environments. There are also plans to visit vessels transiting the Seaway. 4.1.6 Changes in Communication Procedures Effective 01 May 2002, SLSMC introduced new communication procedures for all free-standing bridges between Montreal and Port Colborne. The bridge operator will now make a VHF radio call on the normal working channel to the last vessel through the bridge draw, immediately prior to initiating the bridge lowering / closing sequence. The burden to respond, in the event of a problem, lies with the vessel. 4.2 Action Required 4.2.1 Fitness for Duty and Employee Supervision in Safety-sensitive Positions The Board acknowledges that SLSMC has expressed positive intentions in response to safety deficiencies raised throughout this investigation. In response to MSANo08-01 dealing with medical fitness of employees, SLSMC outlined a number of steps including identifying safety-sensitive positions, drafting a new policy on alcohol and drug testing and updating attendance and sick leave procedures. In response to MSANo03-02, dealing with supervision of bridge operators, SLSMC indicated they had increased the number of supervisory positions, and implemented new procedures for shift handover and communication between vessels and structures. However, the Board is concerned by SLSMC's philosophy toward the issue of ensuring fitness for duty which was outlined subsequent to these safety communications. The position adopted by SLSMC with respect to fitness for duty is as follows: all operating positions (operations and maintenance) are deemed to be safety-sensitive positions; individuals are deemed to be fit in accordance with the selection process, medical pre-employment and other procedures agreed with the Union; fitness for duty is a decision made by a contract physician following a clinical evaluation and information made available by the employee to the employer; and the regime in place for monitoring the medical fitness of employees was in line with the Human Rights Act on the disclosure of personal information. These policies, in combination, provide limited opportunity and responsibility for peers, supervisors and managers to identify and deal with employees whose fitness for duty may be compromised for any reason. While it is likely that the regime in place for monitoring medical fitness of employees is not in contravention of the Canadian Human Rights Act, the legislation may permit greater monitoring than is currently exercised by SLSMC. In June 2002, the Canadian Human Rights Commission issued its Policy on Alcohol and Drug Testing. The underlying philosophy is one of detection and prevention of workplace impairment of all sorts. In particular, it states: There are many causes of employee impairment besides alcohol and drug use that jeopardize workplace safety, such as fatigue, stress, anxiety and personal problems. The Commission encourages employers to adopt programs and policies that focus on methods of detection of impairment and safety risks, and that are remedial rather than punitive in nature. These would include employee assistance programs, enhanced supervision and observation, and positive peer reporting systems, which focus on rehabilitation rather than punishment. Testing should be limited to determining actual impairment of an employee's ability to perform or fulfill the essential duties or requirements of the job. In implementing such a philosophy, the employer has some latitude, particularly where positions are deemed to be safety sensitive. For the purposes of the policy: a safety-sensitive job is one in which incapacity due to drug or alcohol impairment could result in direct and significant risk of injury to the employee, others or the environment. For example, recent cases before the courts have clarified that mandatory disclosure of previous or current alcohol or drug abuse is permissible under the Canadian Human Rights Code for safety-sensitive positions. It is also conceivable that such mandatory disclosure of the use of prescription medication could be justified as a Bona Fide Occupational Requirement under section15 of the Act, providing reasonable accommodation is considered for affected individuals. The Act also allows for reasonable cause or post-incident testing for either alcohol or drugs in safety-sensitive environments in certain circumstances (i.e. where the testing is part of a broader program of medical assessment, monitoring and support). Therefore, given the limited opportunities for SLSMC management to identify employees who may be experiencing personal problems which could affect their fitness for duty, SLSMC should review their supervision and monitoring with respect to fitness for duty to the full extent permissible under human rights legislation. The Board therefore recommends that: The St. Lawrence Seaway Management Corporation reassess and clearly identify safety-sensitive positions in their organization in which incapacity due to impairment could result in direct and significant risk of injury to the employee, others or the environment. M02-01 The St. Lawrence Seaway Management Corporation establish programs and policies which are pro-active and promote early detection of impairment and safety risk of employees occupying safety-sensitive positions by management, supervisors or peers and which provide an effective mechanism for remedial action. M02-02 4.2.2 Emergency Preparedness Decisions about response actions need to be made before an emergency occurs and documented in a contingency plan for the benefit of those who may be involved in the response. However, periodic exercising of the plan is critical to evaluate the state of preparedness. Exercises provide plan holders with feedback on the effectiveness of the plan (and their response system); lessons learned can be applied to improve both the plan and training of response personnel. Typically, a response to a major vessel-related emergency involves various agencies and organizations, each of which requires coordination and integration within the overall response. In response to this accident, SLSMC established an emergency planning committee which will be responsible for, inter alia, coordination of its contingency plan with external agencies, and the development of training programs and exercises. This ongoing work is expected to be completed by year end. An emergency preparedness policy has been developed; one of its guiding principles is the strengthening of co-ordination with external response agencies. Ongoing work by SLSMC concerning its preparedness for responding to vessel-related emergencies is noted by the Board. However, the Board is concerned that there has been no indication from the Corporation that it will undertake a multi-agency, vessel-related emergency response exercise. Such exercises are necessary to evaluate preparedness for responding to a major emergency. Other agencies have conducted similar exercises within the St.Lawrence River and GreatLakes, but there has been limited participation by SLSMC. It is also noted that the Saint Lawrence Seaway Development Corporation, an American government corporation responsible for the operation of the Seaway within the territorial limits of the UnitedStates, has, since 1992, participated in or hosted annual vessel-related emergency exercises involving their local, state and federal agencies. During the 1999-2000 navigation season there were 3141 vessel transits through the WellandCanal, including petroleum and chemical product carriers. Vessel-related emergencies occurring in close proximity to populated areas situated along the Seaway, including the WellandCanal, may pose a risk to the safety of the population in those areas. Consequently, such emergencies present unique challenges for responders in which a coordinated and integrated response among responding agencies is necessary. No major vessel-related emergency response exercise involving other agencies has been conducted within the WellandCanal. Given that risks associated with an improperly coordinated response are higher than that associated with a fully-coordinated response, the Board therefore, recommends that: The St. Lawrence Seaway Management Corporation conduct, in collaboration with the other appropriate authorities and organizations, exercises to respond to vessel-related emergencies which may be encountered within the Seaway, including the WellandCanal, in order to evaluate the preparedness for responding to a major vessel-related emergency. M02-03 Following commercialization of the Seaway in which SLSMC is responsible for Canadian operations, there has been little, if any, oversight provided by TC to ensure that emergency plans, training and exercises were in place and adequate to respond to vessel-related emergencies. Although the Corporation is responsible for Seaway operations, TC retains regulatory authority and is responsible to ensure that arrangements are in place for dealing with vessel-related emergencies within the Seaway. The Board therefore recommends that: The Department of Transport ensure that overall preparedness is appropriate for responding to vessel-related emergencies within the Seaway. M02-04 Assessment/Reassessment Rating: Fully Satisfactory 4.2.3 Bridge Defences Against Inadvertent Lowering A 1982 study by TC, titled Vulnerability of Bridges in Canadian Waters, recognized that lift span or swing bridges over narrow waterways are statistically more prone to collision with vessels. The study reported, inter alia, that: In considering the bridge characteristics, it is necessary to look at the operational aspects as well as the physical and structural factors, all of which must be viewed in the context of the total bridge environment. The operation of any SLSMC lift bridge involves close interaction between the operator, TCC personnel, the bridge, and its equipment; and, that diligence and situational awareness of the bridge operator be uncompromised. However this investigation has identified deficiencies involving the performance of the bridge operator, and management oversight associated with the operation of Bridge11 on the night of the occurrence. These deficiencies included the following: the SLSMC regime in place for monitoring the medical fitness of employees, particularly those in safety-sensitive positions, was less than adequate; safety-sensitive positions were not identified or defined within SLSMC and the monitoring system in place was inadequate to ensure that individuals occupying those positions were competent and fit for duty; bridge operators spent a significant amount of time working alone, and there was little opportunity for management to ensure that they can consistently perform their job functions in an appropriate and safe manner; and it is likely that the bridge operator's performance was impaired at the time of the occurrence. In the circumstances which existed at Bridge 11 on the evening of the occurrence, a bridge operator working alone did not represent an adequate defence against the inadvertent lowering of the lift span on to passing vessels. Suitable backup arrangements are therefore essential to prevent the bridge from being lowered inadvertently. A consultant, hired by SLSMC to review potential physical defences against premature closing of bridges, indicated that such technical arrangements are not in widespread use throughout North America. TSB notes that, whereas Welland Canal bridges operated from a remote location are extensively monitored by video cameras, the camera monitoring of Bridge11 was not adequate to allow TCC personnel to effectively monitor the bridge environment. Additionally, TSB has determined that infrared technology, to detect the presence of vessels in the proximity of bridges, is in use on some lift bridges under the jurisdiction of the United States Coast Guard. As a result of this occurrence, SLSMC has restructured its operations and created additional supervisory positions, implemented procedural changes requiring shift supervisors to visit each bridge on every shift, and modified communication procedures between bridge operators and vessels. Additionally, a long term program has been initiated to automate bridges in the Welland Canal area. The Board is encouraged; measures taken by SLSMC are positive steps towards correcting procedural and supervisory deficiencies noted in the report. The Board notes however that, in the absence of effective backup monitoring systems, the competence of the bridge operator continues to be the sole line of defence against the inadvertent lowering of the span onto a vessel. The Board therefore recommends that: The St. Lawrence Seaway Management Corporation ensure that physical and administrative defences are in place to ensure that Seawaybridges are prevented from coming into contact with transiting vessels. M02-05 4.3 Safety Concerns 4.3.1 Accessibility of Fire Control Plans Without readily available fire plans, shore-based fire departments, whose knowledge of the shipboard environment may already be limited, do not have access to information on the disposition of the vessel's fire fighting equipment. The Board notes that TC is conducting a review of the Fire Detection and Extinguishing Equipment Regulations. However, the Board is concerned that, in the interim, without a requirement for such plans to be stored in a location outside the deckhouse on Canadian non-convention vessels, inaccessibility of the ship's fire control plans may continue to hinder the firefighting capability of municipal fire departments, thereby increasing the risk of personnel injury and damage to property. 4.3.2 Installation of Sprinkler Systems Examination of the sprinkler system on the Windoc subsequent to the occurrence indicated that pipework had been secured to wooden structures. Once the fire destroyed the wooden components of the accommodation, the unsupported sprinkler pipework collapsed, rendering it unserviceable. Subsequent to two fatal fires involving Canadian vessels in 1979 and 1981, many older Canadian flag vessels were retrofitted with such sprinkler systems throughout their accommodation structures. The Board is therefore concerned that, such other older vessels may have retrofitted sprinkler systems attached to combustible internal structures, in a manner similar to the Windoc, and that exposure of such systems to fires may negate their effectiveness.